Patellofemoral Joint Pain
Patellofemoral joint refers to the articulation between the knee-cup and the long bone of your upper leg. This joint is highly mobility and helps to distribute load from the muscles to the bones. Its mobility depends on several factors such as muscle stability and balance, joint appearance and forces directed in the knee. Pain in this joint is likely to be a combination of the latter. In runners it is common and especially in the athlete with poor balance between the muscles.
The pain in this joint will be either acute with a sudden movement while running or may have a gradual onset and worsens over time. It is activity dependent therefore periods of less intense training may reduce your symptoms. However, increase of your training load again may result in the recurrence of this issue.
Examination is aiming to identify weakness, body alignment and technique as well as other contributing factors that result to this pathology. A structured assessment may show underlying weakness in the gluteal muscles and potential hyperactivity in adductor muscles and hip flexors. In addition, a technique analysis may reveal a running style that will predispose to this pathology.
The management of the patellofemoral joint pain will be conservative with specific physiotherapy techniques aiming to relieve the symptoms. Secondly the rehabilitation will continue aiming to prevent recurrence of the pain addressing potential contributing factors that have been identified from the examination.
Jumper’s knee or patellar tendinopathy are synonyms and refer to pain originating from the patella tendon. The patella is the knee cup that it is held in position through various muscles. In addition, it assists to extend the lower leg through force produced from the quadriceps and transmitted through the patella tendon. The tendon is a structure with condensed fibers that is can be compared to a car spring. It has a strong but elastic component able to allow for more ergonomic movements in our life. Irritation of this tendon may lead to pain due to overload.
Examination will reveal pain over the patella tendon and may have difficulty with descending stairs or simply pain with or after sporting activities. The pain is well localised and it presents as a pin point pain that may limit athlete to perform activity. Diagnosis is made with a combination of symptoms and functional limitation. To confirm a diagnosis, ultrasound scanning may be requested.
The management of patella tendinopathy is conservative and includes rest from aggravating activities and ice followed by gradual strengthening of the tendon. Other structural abnormalities or muscle imbalances may be responsible for the overloading of the tendon and are address through the rehabilitation. Return to full level of competition is achieve within 3-6 weeks, however symptoms may last for several months but may not be as severe.
Foot stress fracture
Stress fracture refers to the bone fracture with the absence of a specific event due to overload. This type of foot injury is not uncommon in athletics and results from inadequate rest between training or due to biomechanical abnormalities leading to extreme loading in one area of the foot. This will result to pain and tenderness and may limit the individual from normal day to day activities.
Examination will reveal pain and tenderness over the affected bone and swelling or bruising will normally be absent. Different footwear may feel better, as more protected and strong shoes with a soft sole will be more tolerable. Confirmation of suspected diagnosis is done through an MRI-scan that will reveal increase irritation over the affected bone.
The management of foot stress fracture is commonly conservative and involves rest and protection with a boot and crutches for 8-12 weeks. Then gradual return to sporting activities as well and correction of muscle imbalances is regained with physiotherapy.
1. Hip and Groin Pain
Hip and groin pain can be multifactorial in nature and the most common presentations are described below:
It is a painful condition in the groin due to underlying morphological abnormalities of the hip joint. However, underlying abnormalities may be present on radiological examination but without pain and it is common in the majority of population. A non-symptomatic femoroacetabular impingement is more likely to become symptomatic with athletes or due to changes in activities or training. The grading of the pathology depends upon your clinical presentation and not on your radiological imaging.
Symptoms include intermittent catching pain in the groin region with specific positions of the hip, such as flexion when the knee approximates the chest or rotation, as so in athletics. This condition rarely affects sleeping and it is normally pain-free soon after cessation of aggravating activity or position. If the pathology has been present for a while, inflammation will result in more generalised pain that can become a constant ache and can affect other structures. It can also lead to morning stiffness or stiffness after a period of rest, which will ease off with a few minutes of walking. Pain medication and especially anti-inflammatories can temporarily relieve the symptoms but it is important to understand that it will not cure the underlying condition. Signs of bruising or inflammation are rarely seen with a naked eye but examination will reproduce the symptoms. If there is a need for confirmation, further imaging may accompany the clinical examination.
2. Labrum tear:
The labrum is a fibrocartilaginous structure that surrounds the joint and it is necessary for stability. Tears in the labrum are frequently seen in the athletic population but they also develop in the ageing population. A tear in the labrum is most commonly causing groin pain but it can also result into buttock pain.
Symptoms are similar to the latter and include intermittent catching pain in the groin region with specific positions of the hip, such as flexion when the knee approximates the chest or rotation. This condition may affect sleeping and symptoms are likely to last for a few hours after cessation of aggravating activity. Symptoms of locking, clicking, catching and giving way may be present in the symptomatic population. If the pathology has been present for a while, inflammation will result in more generalised pain that can become a constant ache and affect other structures. It can also lead to morning stiffness or stiffness after a period of rest, which will ease off with a few minutes of walking. Pain medication with anti-inflammatories may temporarily relieve the symptoms but it is important to understand that it will not cure the underlying condition. Signs of bruising or inflammation are rarely seen with a naked eye but examination will reproduce the symptoms. Confirmation requires further imaging which may accompany the clinical examination.
3. Tendinopathy related groin pain
Pain in the groin area can be a result of adductor muscle tendinopathy or hip flexor tendinopathy. It is present normally with sudden increase in activity or training levels or a result of secondary irritation in the presence of the abovementioned. Usually it presents as stiffness at the groin and pain appears at the beginning of the training but then is relieved with continuation of activity. If this condition has been present for a while it may not be relieved with continuation of aggravating activities and may even become painful with activities of daily life.
The management of the abovementioned is similar as they are interconnected. It includes a combination of activity modification to protect the affected area from further irritation and evaluation of sporting technique will allow the clinician to advise you on changes that can be made according to your pain. Followed by exercise rehabilitation beginning with simple exercises which are the basis for then progressing and loading the joint to allow for necessary adaptations in posture and structures in order for you to return to your sport. In addition, in the initial stages, ice or pain medication may be advised to allow for progression with exercise rehabilitation. Manual techniques may be used with to decrease your pain and improving function. Other treatment modalities may be considered depending on your symptoms and rehabilitation is tailored towards each individual.
In severe cases operation of the labrum and femoroacetabular impingement may be considered and it is very unlikely that this will be the choice for primary tendinopathy. Following your operation, the rehabilitation will begin with a combination of ice and pain medication as well as using crutches in the initial days. This will be combined with simple lying down or standing exercises to re-activate muscles that are now malfunctioning due to the operation. As you progress the pain from the operation will decrease and you will be able to tolerate walking and more exercises. Then progressive exercise rehabilitation and manual techniques may be used as in the non-operative approach.
Hamstring tendinopathy in athletics can be present. The hamstring is a large muscle located at the back of the leg and is main function in bending the knee and extending the hip. These movements are necessary for running and weakness, fatigue or muscle imbalances may lead to injury.
The symptoms of a hamstring tendinopathy will have a gradual onset of pain while running that feels tight and can be painful while running. Depending on the severity of tendinopathy, there may pain and tenderness or just tightness with a general ache. Sleeping is not commonly affected. During the morning the feeling of stiffness may be experienced and it is normally relieved with walking. The pain may range from mild ache to severe discomfort depending on the irritation of the underlying structures and your daily activities.
Examination will commonly reveal a tenderness on palpation of the affected leg without bruising. There may be pain on functional activities and the most provocative testing will be bending the knee against resistance.
The management of a hamstring tendinopathy ranges from 2-8 weeks. Management is exclusively conservative and initiates with relative rest, application of ice and compression. Following this a gradual loading program will be recommended by your physiotherapist in order to restore full capacity in the muscle and correct underlying weaknesses and muscle imbalances that are predisposing to injury. Following successful strengthening program, sport-specific rehabilitation will follow with the aim of re-introduction to sport.